Health information is the data related to a person's medical history, including symptoms, diagnoses, procedures, and outcomes. A health record includes information such as: a patient's history, lab results, X-rays, clinical information, demographic information, and notes.
A release of information is a legal document that allows patients to specify what parts of their medical records they want to be made public, to whom they want those parts made public, for how long, and under what legal restrictions or rules.
An EMR system comprises five components: data capture, information management, decision support systems, order entry systems, and reporting mechanisms. These components are essential for providing providers with timely and accurate patient information to inform treatment decisions.
Components of a medical record include essential patient identification information, detailed medical history, medication and treatment records, lab results, progress notes, and documentation such as consent forms. These elements work together to provide a holistic view of the patient's health status and care journey.
In a hospital setting, medical records comprise comprehensive details about a patient's medical history, diagnosis, course of treatment, and follow-up care.
Each Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.
(a) Patients may authorize the release of their health care information by completing the CDCR 7385, Authorization for Release of Protected Health Information , to allow a family member or friend to request and receive an update when there is a significant change in the patient 's health care condition.
Under the California Confidentiality of Medical Information Act (CMIA), patient medical records may not be disclosed without authorization unless disclosure is required for litigation or is required to communicate important medical information to other healthcare providers, insurers, and other interested parties.
All employees have the right to keep their medical conditions confidential if they wish. Rather, an employer should ask if their recent medical history is preventing them from performing the job tasks they used to do before the illness.
What is CMIA? The Confidentiality of Medical Information Act (CMIA) is a California law that protects the confidentiality of individually identifiable medical information obtained by health care providers, health insurers, and their contractors.